| NPI | 1093157554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SD D1034) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SD 438) |
| Enumeration Date | 2013-07-25 |
| Last Update Date | 2018-06-04 |